Opioid prescribing guideline significantly decreases prescription rates

The United States is in the midst of a crisis regarding the abuse of prescription drug opioids. According to the Centers for Disease Control and Prevention, the U.S. death rate from prescription opioid overdose now exceeds the combined death rates from heroin and cocaine.

Acute care settings are a major source of opioid prescriptions, often for minor conditions and chronic noncancer pain. Emergency physicians have identified themselves as targets for patients who seek opioids for nonmedical purposes. Given the difficulty in striking a balance that provides appropriate analgesia for patients without creating or exacerbating drug dependence, the U.S. Department of Health and Human Services recommends the synthesis of pain management guidelines and the creation of clinical decision support tools.

Temple University Hospital (TUH) and Temple University Hospital-Episcopal Campus (TUH-Episcopal) were among those that created a guideline for prescribing opioids in order to maximize safety and avoid misuse.

"The impact of this type of guideline had never been studied in an acute care setting," says Daniel del Portal, MD, FAAEM, Assistant Professor of Clinical Emergency Medicine at the Lewis Katz School of Medicine at Temple University, Assistant Director of Clinical Operations at TUH and Jeanes Hospital, and principal investigator of the study. "We hypothesized that the rate at which opioids were prescribed in the emergency department for dental, neck/back and chronic pain would decrease after adoption of the guideline. We also hypothesized that physicians would support the use of the guideline."

The retrospective observational study compared the rate of opioid prescriptions for dental, neck/back and chronic noncancer pain before and after adoption of the guideline in January 2013. The research team used data from 13,187 patients aged 18 years or older who met the diagnosis criteria and were discharged from the emergency departments at TUH and TUH-Episcopal.

The team also administered a survey to the faculty emergency medicine physicians who were practicing in the two emergency departments.

Results showed the prescribing guideline had an immediate and sustained impact in reducing opioid prescribing rates for all age groups and for each of the three categories of complaints with a high degree of statistical significance. Also, 100% of physicians surveyed supported implementation of the voluntary guideline. Most (97%) felt the guideline had facilitated discussions with patients when opioids were being withheld, and nearly three-quarters of respondents reported encountering less hostility from patients since adoption of the guideline.

"Emergency physicians and other acute care providers can use various tools to promote the rational prescribing of dangerous opioid medications," adds Dr. del Portal. "In contrast to electronic prescription drug monitoring programs, which show promise but require significant infrastructure and regulation (and are as yet unavailable to prescribers in Pennsylvania), an easily implemented guideline empowers physicians and protects patients from the well documented dangers of opioid misuse."